Critical Care Medicine Specialists Research Articles

A Primer on Chimeric Antigen Receptor T-cell Therapy-related Toxicities for the Intensivist.

Chimeric antigen receptor (CAR) T-cell therapy is an innovative treatment approach that has shown remarkable efficacy against several hematologic malignancies. However, its use can be associated with unique and sometimes severe toxicities that require admission to intensive care unit in 30% of patients, and intensivists should be aware of immune-mediated toxicities of CAR T-cell therapy and management of adverse events. We will review available literature on current diagnostic criteria and therapeutic strategies for mitigating these most common toxicities associated with CAR T-cell therapy including cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) in the post-infusion period. The authors will also review other toxicities associated with CAR T-cell therapy including cytopenias, acquired immunocompromised states, and infections, and discuss the available literature on best supportive care and prophylaxis recommendations. Critical care medicine specialists play a crucial role in the management of patients undergoing CAR T-cell therapies. With the expanding use of these products in increasing numbers of treating centers, intensivists' roles as part of the multidisciplinary team caring for these patients will have an outsized impact on the continued success of these promising therapies.

Need Analysis of Indian Critical Health Care Delivery in Government Sectors and Its Impact on the General Public: A Time to Revamp Public Health Care Infrastructure.

Poverty is directly linked to public health care delivery in many ways and dimensions. Every aspect of the human sphere is preplanned, but a health crisis is the only emergency which pushes humanity into severe economic stress. Therefore, every nation aims to safeguard its citizens from a health crisis. In this aspect, India needs to improve its public health infrastructure in order to protect its citizens and save them from poverty. (1) To assess the current pitfalls in public critical health care delivery, (2) to analyze whether the health care delivery matches the requirements of its population in every state, (3) to produce solutions and guidelines to overcome the stress in this priority area. Data regarding the critical care workforce, which includes critical care doctors and nurses, were taken from official websites and other sources. Critical care infrastructure data were retrieved from the Internet sources. Data were validated by consulting state government sources and cross-checked for bias elimination. The data were analyzed using the "Statistical Package for Social Sciences" software version 20, and were presented using descriptive statistics. There is a 1:10 percentage of deficit in the case of critical care workforce and infrastructure when compared with its need analysis. Critical care medicine specialists are in 1:75 when compared to other specialties. Overall, the public sector critical care needs a total boost through out of box solutions. According to the Stockholm International Peace Research Institute (SIPRI), India spent the third most on defense in the world in 2021. India spent 76.6 billion dollars on its military in 2021, up 33% from 2012 and 0.9% from 2020. However, since India is considered a fast-growing economy, there is still a huge disparity in critical care. Without resetting critical health care, India cannot grow in welfare indices even if it is among the top gross domestic product (GDP) countries. Prabu D, Gousalya V, Rajmohan M, Dinesh MD, Bharathwaj VV, Sindhu R, et al. Need Analysis of Indian Critical Health Care Delivery in Government Sectors and its Impact on the General Public: A Time to Revamp Public Health Care Infrastructure. Indian J Crit Care Med 2023;27(4):237-245.

Comparison and Reflection on the Training System of Foreign Critical Care Medicine Specialists

Comparison and Reflection on the Training System of Foreign Critical Care Medicine Specialists

Expert consensus statement on therapeutic drug monitoring and individualization of linezolid.

Linezolid is an oxazolidinone antibacterial drug, and its therapeutic drug monitoring and individualized treatment have been challenged since its approval. With the in-depth clinical research of linezolid, we have changed our attitude toward its therapeutic drug monitoring and our view of individualized treatment. On the basis of summarizing the existing clinical studies, and based on the practical experience of each expert in their respective professional fields, we have formed this expert consensus. Our team of specialists is a multidisciplinary team that includes pharmacotherapists, clinical pharmacology specialists, critical care medicine specialists, respiratory specialists, infectious disease specialists, emergency medicine specialists and more. We are committed to the safe and effective use of linezolid in patients in need, and the promotion of its therapeutic drug monitoring.

Connect with each other, help each other, and make progress together: thoughts on the construction of Critical Care Medicine Specialist League in Henan Province

Critical care medicine has developed rapidly and has become an indispensable comprehensive subject in clinical medicine at home and abroad. In recent years, the government has vigorously implemented the "Healthy China" strategy and strived to achieve a higher level of national health. The Henan Provincial People's Hospital has set up a network of interconnected "Wisdom Critical Care Medicine Specialist League" to meet the major strategic needs of the country, and to play a role in attracting large hospitals to promote the sinking of quality medical resources and the improvement of grassroots service capabilities. Complementary advantages and resource sharing are conducive to achieve win-win cooperation and coordinated development between the third-grade class-A hospital and grassroots hospitals.

Figure 1: An App Review

Figure 1 is a mobile-first network of hundreds of thousands of healthcare professionals sharing and discussing medical cases.1 Dr. Joshua Landy, a critical care medicine specialist, and Gregory Lev...

Analysis of the characteristics of interconsultations performed by emergency physicians to other hospital specialists and their evolution over time

The objective of this study was to describe the type of interconsultations carried out in the Emergency Department (ED) to hospital specialists and analyze their pattern over time. The study was carried out during the period from 2006 to 2012. It was carried out at EDs attending to all types of interconsultations except pediatrics and obstetrics-gynecology. There were no changes in physical structure, number of personnel, or organization during the study period. The main measurements taken were as follows: monthly ED census, number of interconsultations and specialties consulted, main reason for presentation at the ED during the first (2006) and last year (2012), and, for specialties demonstrating substantial quantitative changes, main reasons for the interconsultation from the ED at the beginning (2006) and the end (2012) of the study. Linear regression analysis was carried out for the relationship between time and number of interconsultations. A total of 628 256 care interventions were carried out, with 128 008 interconsultations (20.4%). Orthopedic surgery and traumatology, psychiatry, and general and digestive surgery were the departments most frequently consulted (54.5% of the interconsultations). Consultations significantly reduced over time (R=0.29; P<0.001) but the percentage of interconsultations (related to ED census) remained unchanged (R=0.01; P=0.49). The behavior related to specialties was heterogeneous: consultations to general and digestive surgery, hematology and hemostasis, and urology specialists decreased, whereas to thoracic surgery, angiology and vascular surgery, neurology, nephrology, neurosurgery, psychiatry, orthopedic surgery and traumatology, and critical care medicine specialists increased. Some of the reasons for specialist consultation also significantly changed over time. The study of interconsultations allows us to identify areas of lesser autonomy of emergency physicians. Changes in the pattern of these interconsultations over time may reflect both learning processes and changes in the healthcare circuits in the ED.

Effect of Nitric Oxide Synthase Inhibition on Body Temperature Control During Endotoxemic Shock

Septic shock is a major cause of death following trauma and a persistent problem in surgical patients. It is a challenge to the critical care medicine specialist and carries an unacceptable high mortality rate, despite adequate antibiotic and vasopressor therapies. The prevalent hypothesis regarding its mechanism is that the syndrome is caused by an excessively defensive and inflammatory response. During the acute phase, some signaling mechanisms are activated, particularly changes in body temperature and hormonal release, which function to restore the host homeostasis that has been disturbed by the infection. Since the neuroendocrine and immune systems are functionally related, the exposure to antigens induces a synchronized response, which allows the organism to successfully endure immunologic changes. An important characteristic of this communication includes the appearance of proteins released into the circulation by activated immune cells. These proteins, called cytokines, may enter the circulation and reach neuroendocrine organs, where they either act, themselves or through the release of intermediates such as nitric oxide (NO). NO is a gaseous and free radical molecule, synthesized by nitric oxide synthases (NOS) during conversion of L-arginine in L-citrulline. These enzymes involve three different isoforms, neuronal, endothelial and inducible. The first and most common function attributed to NO is its role in controlling vascular tonus. Besides vasodilatation and antimicrobial defense, it has been demonstrated that NO has other functions, including body temperature control. The synthesis of NO may also be induced in the brain as a consequence of infection and may alter the function of the hypothalamic-pituitary axis. In this review we propose to discuss the pathophysiological effects of NOS inhibition in body temperature regulation during experimental sepsis and septic shock.

Neuro-Immune-Endocrine Mechanisms During Septic Shock: Role For Nitric Oxide in Vasopressin and Oxytocin Release

Septic shock is a major cause of death following trauma and a persistent problem in surgical patients. It is a challenge to the critical care medicine specialist and carries an unacceptably high mortality rate, despite adequate antibiotic and vasopressor therapy. The prevalent hypothesis regarding its mechanism is that the syndrome is caused by an excessive defensive and inflammatory response. During the acute phase some signalling mechanisms are activated, particularly hormone release, which function to restore the host homeostasis that has been disturbed by the infection. Since the neuroendocrine and immune systems are functionally related, so the exposure to antigens induces a synchronized response, which allows the organism to successfully endure immunology changes. An important characteristic of this communication includes the appearance of proteins released into the circulation by activated immune cells. These proteins, called cytokines can enter the circulation and reach neuroendocrine organs, where they act either themselves or through the release of intermediates such as prostaglandin, catecholamines and nitric oxide. The synthesis of nitric oxide may be induced in brain as a consequence of infection and may alter the function of the hypothalamic-pituitary axis. In this review we discuss the physiologic roles of the nitric oxide in central nervous system controlling the regulation of vasopressin and oxytocin during the pathophysiology of sepsis.

The Critical Care Professional Societies Address the Critical Care Crisis in the United States

T he four major critical care societies in the United States—the American Association of Critical Care Nurses (AACN), the American College of Chest Physicians (ACCP), the American Thoracic Society (ATS), and the Society of Critical Care Medicine (SCCM)—have united in their efforts to address the manpower shortage of health-care providers who care for the critically ill. This is one of the most pressing issues affecting the future of our aging population and American medicine. While it has been generally acknowledged and widely appreciated that the shortages in nursing, respiratory care practitioners, and pharmacists have already reached crisis levels, there had been conflicting forecasts of the adequacy of the present and future physician labor market throughout the 1990s.1–4 Because of this, the ACCP, ATS, and SCCM formed the Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS) in 1995 and commissioned a study with the following goals: (1) determine current patterns of care for the critically ill and patients with pulmonary disease, (2) anticipate how demand for care might change in the future, and (3) project supply based on the current workforce and training. The COMPACCS study,5 published in 2000, has convincingly predicted that the aging of the population of the United States will create a demand for care that will outpace the future supply of critical care medicine specialists, and that the effects of this shortfall in manpower will start to reach crisis proportions after 2007. Shortly after the COMPACCS study was published, the ACCP, ATS, and SCCM came to the realization that they needed to join forces with the AACN to reverse the manpower shortages and their worsening trends, and that they needed to become actively engaged in trying to help solve the issues within their power. Therefore, in 2001, these four societies, collectively representing 100,000 healthcare professionals, formed the Critical Care Workforce Partnership that promptly set out to accomplish two goals. The first was to analyze the current models of how critical care medicine was being delivered in the United States and what the four societies could do together to help alleviate the pressures that the manpower shortages were creating for their patients and their members. The results of this analysis and recommendations for action are the subject of the FOCCUS (Framing Options for Critical Care in the United States) Task Force report in this issue (see page 1514). The second goal was to develop strategies to work with public policy makers to make short-term and long-term changes at the federal level that would favorably impact the reduced critical care provider workforce. The results of this effort are the subject of the report by Ewart and colleagues in this issue entitled “The Critical Care Medicine Crisis: A Call For Federal Action” (see page 1518). During the writing of this white paper, the ACCP, on behalf of the Critical Care Workforce Partnership, had the opportunity to consult with members of Congress *From the Pulmonary, Allergy, and Critical Care Medicine Division (Dr. Irwin), University of Massachusetts Medical School, Worcester, MA; and the American College of Chest Physicians (Ms. Marcus and Mr. Lever), Northbrook, IL. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: permissions@chestnet.org). Correspondence to: Richard S. Irwin, MD, FCCP, Pulmonary, Allergy, and Critical Care Medicine Division, U Mass Memorial Medical Center, 55 Lake Avenue North, Worcester, MA; e-mail: irwinr@ummhc.org special reports

Textbook of Critical Care,

Since the first edition of the Society of Critical Care Medicine's Textbook of Critical Care was published in 1984, critical care medicine has emerged as a recognized subspecialty in the disciplines of pediatrics, surgery, anesthesiology, and internal medicine. The American Board of Pediatrics certified its first cohort of pediatric critical care medicine specialists in 1987. Pediatric critical care is expanding as a clinical, teaching, and research discipline in the 1980s, much as neonatology expanded in the late 1960s and early 1970s. There has been a concomitant proliferation of related textbooks. Oftentimes, second editions of textbooks are merely updates of the previous edition. Happily, these editors were far more ambitious. This edition is better organized and written. The first edition exhibited the marked unevenness in style and content that plagues many multiauthored textbooks. These editors clearly molded the second edition into a more cohesive textbook. The number of chapters has increased

Continuing Care of Multiorgan Donor Patients

Preserving the optimal function of donor organs must be the primary goal of physicians caring for patients who have been certified brain dead and from whom organs will be transplanted. During the hours before organ removal, several significant medical challenges may emerge. These challenges include restoration and maintenance of intravascular volume and cardiac output to assure adequate oxygen delivery to donor tissue; re suscitation of the patient from spontaneous cardiac ar rest ; evaluation and reversal of polyuria; management of poikilothermia and the effects of hypothermia; and treat ment of hypopituitarism and other possible changes in circulating hormones. Individual organ function and the interdependency among donor organs must be carefully monitored and balanced to assure that the recipient re ceives organs that have the best opportunity for optimal primary function. Care of the multiorgan brain dead pa tient and his or her family requires a multidisciplinary team skilled not only in the medical and surgical aspects of transplantation but also in the care of families who have suffered loss. A new focus for patient care is appropriate after the decision has been made that a patient is brain dead and will become an organ donor. Because preser vation of brain function is no longer possible, treat ment priorities should shift to maximize perfusion and function of the donor organs. Through careful management of the donor patient, the recipient will receive organs that are less likely to undergo pri mary failure. This discussion will review the physio logical support necessary to sustain brain dead pa tients and to optimize donor organ function until organ removal is completed. It is assumed that indi vidual organs will be assessed and accepted or re jected for donation using criteria established by lo cal organ procurement teams. Such criteria will not be discussed here. The brain dead organ donor presents a variety of management challenges (Table 1) that may extend over many hours while members of transplant teams and organ recipients are assembled and tis sue testing is completed. The responsibility for care may remain with the admitting physician or critical care medicine specialists, or it may be transferred to the transplant service. Coordination, however, remains the key to a successful outcome. The avail ability and interest of a knowledgeable physician to supervise the donor patient's care continues to be crucial because a variety of problems, each capable of rendering donor organs useless, may develop in the hours between brain death and organ removal.